[HSF] Stent-vs-surgery debate heats up again (OT history)

Fri Apr 6 03:18:00 EDT 2007

Dear Ani,
I had not thought of Dwight's baffle as similar to efforts to alter ventricular shape, and frankly I don't think it did. Dwight, Bob Glover, and Charlie Bailey all tried external umbilical tape  purse string annuloplasty (riskier , in those days, than coronary sinus annuloplasty but about as effective). 
I think Charlie Bailey's attempts to block the regurgitant orifice (typical of rheumatic insufficiency due to shrunken leaflets) were more remarkable: a baffle (cartilage inside a pericardial tube) positioned in the mitral orifice and anchored at the interatrial groove and the L ventr apex. Charlie Bailey also did an annuloplasty from the outside made with successive shortening  sutures, controlled by a finger in the atrium, after exposing the annulus by dissecting the circumflex and the coronary sinus off the atrioventricular junction!
 The Henry Nichols reference is fascinating. I was at the Mayo Clinic at the time and noone mentioned it: I guess it never caught on. Unlike the term "septolateral" which is repeatedly used, but is anatomically wrong and refers to a single dimension which by itself is only a surrogate for a hemicircle of radii from the middle of the ant  leaflet base to all of the mural annulus. We can talk about that some other time.
Bob

-----Original Message-----
From: anianyanwu at hotmail.com

To: OpenHeart-L at lists.hsforum.com
Sent: Thu, 5 Apr 2007 9:52 PM
Subject: Re: [HSF] Stent-vs-surgery debate heats up again

Dear Dr Frater,

Thank you for your comments. I have checked up on the references.

The first paper I was referring to was by Harken, Black, Ellis and Dexter 
presented at the 34th AATS meeting in 1954. The accompanying manuscript in the 
journal of thoracic surgery the same year titled "The surgical correction of 
mitral regurgitation" describes  a device placed through the ventricle from 
anterior to posterior wall straddling the valve - strictly speaking this was not 
a splint as this device was not just a thread but contained a baffle which would 
help obstruct the residual defect that occurs during systole - while the goal 
was to plug the gap in coaptation, some of the effect of this device however 
would have been achieved by narrowing the septolateral dimension.

The early reference to the edge-to-edge I alluded to was also presented at the 
AATS, but in 1956, by Henry Nichols. His paper was titled "Mitral 
Insufficiency-Treatment by Polar Cross-Plication of the Annulus Fibrosus". He 
described a technique of suturing the anterior to posterior annulus thereby 
creating a double orifice valve which he found cured regurgitation in selected 
patients. In his later work he sutured various areas of the annulus and/or 
leaflets together to treat mitral regurgitation.

Apart from advances in technology (such as endoscopic surgery), I suspect the 
majority of surgical "advances" have been long been previously applied. For 
example the 'innovation' of beating or perfused heart valve surgery will be 
laughed at by many surgeons active in the 1960s because for many this was the 
only way valvular operations were executed in that (pre-cardioplegia) era. My 
previous chief Yacoub was doing homografts on perfused beating or fibrillating 
heart without cardioplegia well into the 1990s. Similarly for all the talk about 
minimally invasive surgery, I did a reoperation on a patient who had an ASD 
repair in the late 1960s - I was puzzled I could not find her scar till I looked 
under her right breast and saw a barely visible 3 to 4 inch incision. The 
easiest way to come up with new ideas is to read the literature form 1940s to 
1960s - then there was no valve replacement and CPB just introduced so the 
literature is abound with innovative ways of curing valve disease without 
prosthetic replacement and some without CPB.

Ani
  ----- Original Message ----- 
  From: rwmfglycar at aol.com<mailto:rwmfglycar at aol.com> 
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
  Sent: Monday, April 02, 2007 10:13 AM
  Subject: Re: [HSF] Stent-vs-surgery debate heats up again

  Dear Ani,
  You are basically right. Most of the cut and sew techniques of surgery were 
developed after anesthesia came along and that takes us back more than a hundred 
years. Look up the history of surgeons who gave their names to instruments 
(often the same instrument with a different surgeon's name depending on which 
country you were in). Check out Metzenbaum, for example.
  There are a few details that have changed: in the early days of vascular 
surgery silk was threaded on a needle, after which the scrub nurse would put a 
blob of vaseline on thumb and forefinger and drag the suture through the 
vaseline to make it pass easily through the vascular wall.
  In the early 70's vein to coronary anastamoses were still being done with 
interrupted silk at the Cleveland Clinic.
  What made cardiac surgery different was the need to duplicate the functions of 
the heart and circulation in order to use those cut and sew techniques that had 
evolved starting in the 19th century. In the last 40 years the greatest advances 
probably came from anesthesia.
  I am puzzled by your description of an Alfieri stitch 60 years ago. Can you 
give me a reference? Neither do I know of Dwight Harken doing any form of 
external splinting experimentally.
  Yours 
  Bob

  -----Original Message-----
  From: anianyanwu at hotmail.com<mailto:anianyanwu at hotmail.com>
  To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>
  Sent: Sun, 1 Apr 2007 11:23 PM
  Subject: Re: [HSF] Stent-vs-surgery debate heats up again

  Michael

  When you say your current operation is not same as Cleveland's 1970s CABG, on 
  what basis do you say this? Certainly you were not around in the 1970s so 
either 
  you just believe so, were told so or read so. I suspect it is not the latter 
  because if you read some of the original descriptions of the procedures we do 
  now, you will be surprised how little has changed. 

  For example, I was last week reading a paper of Dr Starr from 1961 on his 
first 
  8 MVRs in humans and really there has been not much change in the technique of 

  MV replacement in the ensuing four decades. Similarly if you read Barnard's 
'the 
  operation', or indeed Dr Lower's paper a decade earlier, you will see that 
aside 
  from modifications in right atrial anastomosis, heart transplantation 
technique 
  has not changed much. At the beginning of my training I used to read an out of 

  print book from 1981 written by Hank Edmunds called I think atlas of 
  cardiothoracic surgery. I have never come across a better written book on 
  operative technique and I was amazed to find that the book was more than 
  adequate for operative learning of majority of cardiothoracic techniques and 
  procedures I was exposed to as a junior trainee in late 1990s.

  We believe things do change because we can't know all of history and we can't 
  read all the literature, but if we could, we would realize that most of what 
we 
  think is new in surgical technique, has been done or thought of before. For 
  example in the field of mitral repair, the groundbreaking alfieri stitch was 
  described over 60 years ago, external splinting (ala coapsys) was tried 
  experimentally (I believe by Harken but sure Dr Frater will know correct 
  reference) in the 1950s, suture rather than resection of the mitral leaflet 
was 
  described by McGoon in the 1950s etc. Whatever you consider state of the art 
  CABG was done 30 years ago. Koselov was doing off-pump LIMA-LAD via 
thoracotomy 
  (which we now give the sexy name MIDCAB) in 1960s even before Favalaro 
  popularized his operation. We just go round in circles - there are few real 
  original ideas, often just a recirculation of old ones. 

  I sent an report of a novel operative technique to a journal two months ago 
and 
  one of the reviewers said I need to be clear if this a a new technique and add 
a 
  statement to the effect that " we report the first xxxyyy..." I refused 
replying 
  that there are thousands of cardiac surgeons round the world and there is no 
way 
  I can know that someone else has not come up with or used the same technique 
  independently; indeed it would be extremely unlikely that one is the only 
  surgeon past or present to ever have thought up the idea - others either just 
  have not published it or have done but I have not read it (there is literature 

  beyond pubmed) . I often laugh when surgeons describe their 'own' technical 
  innovations and tricks - if you go around the block often enough you will 
often 
  find other surgeons who have independently come up with the same 'original' 
  ideas you have. 

  Whilst there have been some true innovations in the last decade, the essence 
of 
  what we do has not changed that much. The more things change the more they are 

  the same. Maybe the future is in those catheters after all ...now that is 
  progress. Or is it?

  Ani

  PS - I am referring to surgical technique and not to peri-operative management 

  which I agree has changed much...
    ----- Original Message ----- 
    From: Michael Firstenberg<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com>> 

    To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>> 

    Sent: Wednesday, March 28, 2007 7:29 AM
    Subject: Re: [HSF] Stent-vs-surgery debate heats up again

    Hal,
    I agree that we must continue to advance, define, redefine, develop, and
    innovate.  However my question is how many referring Docs (or patients) come
    to you, ask for, want, insist on a specific operation?  I dont deny that a
    subset of people "must have a mini-mitral to beach season" but what is the
    data?  How many patients show up in your office with an internet page and
    say "I want a MIDCAB"?

    Interesting how we have spent the past week, in honor of ACC, slamming
    stents and proclaiming CABG as the greatest thing since sliced bread and yet
    we criticise a 40 year/old operation.  Having spent time in Cleveland where
    CABG was first mass-produced (not discussing "invented") - I can clearly
    attest it is not the same operation.  But, gee - it works and from the data,
    it works well - the concept and the basic application are sound and proven.
    Thinks like incisions, sternal approaches, retractors, oxygenators, shunts,
    wigets, and so on may change - but the basics will be around.  No one is
    doing the same operation that they did 40 years ago (well except that
    surgeon who does not use retrograde).  Hal - do you still drive a car?  Fly
    an airplane?  Watch TV - all old technology using current logic.

    Besides, you sound pretty busy (although you have time to contibute
    frequently to this forum) - you went out and got new business, perfected new
    operations, expanded your product line so to speak.  That is what we need to
    do.  I think the dying surgeons are the open who only want to 3 graft CABG
    on healthy people with normal EFs - those days are gone.  Yes, we still see
    those patients - did 2 last week in fact - but the difference is the
    comorbidities that come with them.  1 had a huge SAH from a ruptured
    aneurysm a few years ago and the other has awful diabetes.  Between the 2
    they had a working pair of eyes and kidneys.  Surgeons who dont take on
    those problems are the ones who dont or wont find work.

    Got to go round, and see the 79 year/old who I took a LVAD out of last
    night..........

    -michael

    On 3/27/07, hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com>> 
<hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aol.com<mailto:hgrmd at aolcom>>> 
  wrote:
    >
    > Michael,
    > The "best, busiest, and most respected surgeons who don't do anything
    > fancy" are a dying breed.  You have to stay cutting edge if you are to
    > remain relevant.  I highly doubt a 40 yo operation (CABG) is going to be 
the
    > mainstay for the rest of your career.  Don't believe me?  Stay tuned.
    >
    > Hal
    >
    > -----Original Message-----
    > From: msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com<mailto:msfirst at gmail.com>>
    > To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com>>
    > Sent: Tue, 27 Mar 2007 7:50 AM
    > Subject: Re: [HSF] Stent-vs-surgery debate heats up again
    >
    >
    > Hal,
    > I think the key is polishing skills - while some patients and referring
    > docs
    > want specific operations or approaches (particularly if offerred) - from
    > what I have seen over the years (granted not too many), is beyond a safe
    > operation and getting discharged alive the approach is a distant second.
    > Although, I have (as we have discussed time and time again), patients,
    > referring docs, and surgeons play too much emphasis on cosmetic results or
    > macho approaches. Patients want someone who cares.
    >
    > Many of the best, busiest and most respected surgeons that I have known
    > dont
    > do anything fancy - they just provide good patient care and safe
    > operations
    > with good outcomes.
    >
    > -michael
    >
    > On 3/26/07, Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com>> 
<Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aol.com<mailto:Hgrmd at aolcom>>> 
  wrote:
    > >
    > > MIchael,
    > > I understand a provincial view when you are polishing your basic skills.
    > > However, if you think no catheters and full sternotomies are the way you
    > > will
    > > practice for the foreseeable future, I predict you'll one day regret
    > that
    > > policy.
    > > Hal
    > >
    > >
    > >
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